Nursing Elites

1. The nurse is assisting with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the nurse take?

• A. Omit the section of the assessment form
• B. Ask her if she would like an interpreter to help her understand the question
• C. Reword the question to make it more culturally sensitive
• D. Observe the client's response when asked a different question

Correct answer: D

Rationale: Observing the client's response to another question is the most appropriate action in this scenario. By doing so, the nurse can assess whether the client's discomfort is due to cultural sensitivity or a misunderstanding. This approach allows the nurse to proceed with sensitivity and respect, ensuring effective communication. Option A is incorrect because omitting the section of the assessment form may result in missing crucial information relevant to the client's condition. Option B jumps to assumptions about a language barrier without confirming it first. Option C focuses on rewording the question without addressing the underlying issue causing the client's discomfort, which may not necessarily be due to a lack of understanding.

2. When teaching a patient with diabetes about foot care, which of the following should the nurse emphasize?

• A. Avoid soaking feet daily to prevent dryness and skin breakdown
• B. Select well-fitting shoes to prevent injury
• C. Trim toenails straight across and file the edges
• D. Avoid using heating pads to prevent burns

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across and filing the edges is crucial in diabetic foot care to prevent ingrown toenails and foot injuries. Soaking feet daily can lead to dryness and skin breakdown, increasing the risk of infection. Selecting well-fitting shoes is important to prevent pressure points and skin damage, not tight-fitting shoes. Using heating pads can result in burns or injuries due to decreased sensation in diabetic feet, so it's essential to avoid them.

3. Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the nurse to review?

• A. Hemoglobin and Hematocrit
• B. Serum Calcium
• C. Serum Creatinine
• D. WBC

Correct answer: C

Rationale: The correct answer is C: Serum Creatinine. Serum creatinine is a key indicator of kidney function. Reviewing this value is crucial as it helps assess the client's risk for nephrotoxicity before administering the antibiotic. Elevated serum creatinine levels can indicate impaired kidney function, which would increase the risk of nephrotoxicity. Choices A, B, and D are not as directly related to kidney function and nephrotoxicity. Hemoglobin and hematocrit levels assess for anemia, serum calcium levels monitor calcium balance, and WBC count evaluates for infections. While these values are important for overall patient assessment, they are not as specific to assessing nephrotoxicity risk as serum creatinine.

4. A client is 48 hours post-op from a bowel resection and has not had a bowel movement. The client is complaining of abdominal pain and bloating. What is the nurse’s best action?

• A. Administer a prescribed laxative.
• B. Encourage the client to increase fluid intake.
• C. Auscultate bowel sounds.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: Auscultating bowel sounds is the best initial action in this situation. It helps the nurse assess bowel function before considering interventions like administering a laxative. Abdominal pain and bloating could be indicative of bowel motility issues, and auscultation can provide crucial information. Encouraging increased fluid intake can be beneficial in promoting bowel movement, but assessing bowel sounds is more immediate to evaluate the current status. Notifying the healthcare provider should be reserved for situations where immediate intervention is needed or if the condition worsens after assessment.

5. How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?

• A. The goals set by the client
• B. The learning level of the client
• C. Assessing the home environment
• D. The distractions in the client's home

Correct answer: C

Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.

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